What Changes for Telehealth Prescribing of Controlled Substances on January 1, 2027

Nothing has been decided yet. As of October 8, 2026, the rule that lets DEA-registered practitioners prescribe Schedule II through V controlled substances by telemedicine without a prior in-person evaluation still expires at the end of December 31, 2026. On January 1, 2027, one of three things will be true: the DEA's special registration rule is in effect, a fifth temporary extension is in effect, or neither is and the Ryan Haight Act's in-person requirement applies again in full. A practice that prescribes controlled substances to patients it has never seen in person needs a plan for all three.

What rule is in force today?

The Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities, published by DEA and HHS at 90 FR 61301 on December 31, 2025, effective January 1 through December 31, 2026. It is codified at 21 CFR 1307.41, and the conditions are short. The prescription must be issued for a legitimate medical purpose in the usual course of professional practice. It must follow a communication using an interactive telecommunications system as defined at 42 CFR 410.78(a)(3), which is two-way, real-time audio and video, with audio-only allowed only where that definition allows it (a patient at home who cannot use, or does not consent to, video). The practitioner must be authorized under a DEA registration to prescribe that class of drug, or exempt from registration. And the prescription must meet every other requirement of 21 CFR part 1306.

Section 1307.41(a) says in so many words that the section "is in effect until the end of the day December 31, 2026."

Where does the special registration rule stand?

DEA proposed it on January 17, 2025 (Special Registrations for Telemedicine and Limited State Telemedicine Registrations, 90 FR 6541). The agency says it received more than 6,475 comments. The Unified Agenda entry for the rule (RIN 1117-AB40) on reginfo.gov lists the final action for November 2026, and McDermott's health law team reported that DEA sent a final rule to the White House Office of Information and Regulatory Affairs for review on August 25, 2026. The text of that final rule is not public. Nothing has been published in the Federal Register as of today.

So we know what DEA proposed, not what it will adopt. The proposal is summarized in our explainer on the special registration as proposed. Treat every term in it as provisional.

What are the three ways January 1 can go?

• A final special registration rule takes effect. Practitioners who want to prescribe without an in-person evaluation would need whatever registration the final rule creates, plus whatever state-level telemedicine registrations it requires. A final rule also usually comes with a transition period; whether this one does, and how long, is unknown. If the rule is published but its effective date is later than January 1, the gap question remains.
• DEA extends the temporary rule again. It has done so four times: May 10, 2023 (88 FR 30037), October 10, 2023 (88 FR 69879), November 19, 2024 (89 FR 91253) and December 31, 2025. The fourth was published on the last day of the year. Planning on a fifth is planning on hope.
• Neither happens. The flexibility lapses. A practitioner then needs at least one in-person medical evaluation of the patient before prescribing a controlled substance by telemedicine, unless one of the statutory exceptions at 21 U.S.C. 802(54) applies. Those are mostly institutional: the patient is in a DEA-registered hospital or clinic, or in the physical presence of another registered practitioner, plus Indian Health Service, VA emergency and public health emergency categories. See the Ryan Haight Act and its exceptions.

Which rules apply no matter what?

Three things survive any of the outcomes above.

• Prior in-person relationships. The fourth extension restates DEA's position plainly: once a practitioner has conducted at least one in-person medical evaluation of a patient, the Ryan Haight Act's remote prescribing requirements "no longer apply to that specific practitioner-patient relationship," regardless of how much time has passed. The evaluation has to be by the prescribing practitioner, in the patient's physical presence (21 U.S.C. 829(e)(2)(B)). A covering practitioner can prescribe for a colleague who saw the patient in the prior 24 months and is temporarily unavailable (829(e)(2)(C)).
• The buprenorphine rule. 21 CFR 1306.51 (90 FR 6504), in effect since December 31, 2025, allows Schedule III through V medications approved for opioid use disorder to be prescribed after an audio-video or audio-only telemedicine encounter for up to six calendar months, with a PDMP check and pharmacist ID verification. After six months, further prescriptions need an in-person evaluation or another lawful pathway. Details in our buprenorphine post.
• The VA continuity rule. 21 CFR 1306.52 (90 FR 6523) covers VA practitioners prescribing to VA patients another VA practitioner has seen in person.

State law also survives all three outcomes. A state that bars Schedule II prescribing by telehealth or requires an in-person visit for chronic pain treatment does so regardless of what DEA does. Start with our state-by-state telehealth law index.

How big is the exposure?

In the preamble to the fourth extension, DEA quoted a stakeholder's summary of unpublished data reviewed by Epic, Johns Hopkins and Stanford: of an estimated 44.6 million controlled substance prescriptions across 258 organizations in 2024, more than 7 million, about 16 percent, were issued without a prior in-person evaluation. For a telehealth-only psychiatry, ADHD or testosterone practice, the share is closer to all of them.

What should a practice do before December?

1. Tag every active controlled-substance patient. For each one, record whether the prescribing clinician has examined the patient in person, when, and where that is documented. This is the single most useful list you can have on December 31.
2. Split the list by drug and schedule. Buprenorphine for OUD has its own pathway. Schedule II stimulants and opioids carry the most risk under every version of the proposal. Schedule III to V drugs such as testosterone and most benzodiazepines sit in the middle.
3. Price an in-person plan. For patients without a prior visit, decide how you would get them seen: your own clinic sites, a partner network, or a hand-off to local prescribers. Do the math on cost and capacity now, not on December 28.
4. Check DEA registrations against patient states. Under the proposal, and under 21 U.S.C. 831(h), the registration question turns on where the patient is located. Practitioners who will need new state DEA registrations should start them early; filings for NPs go through White Glove APRN, for PAs through White Glove PA, and for physicians through White Glove IMLC.
5. Write patient letters in two versions. One for "nothing changes yet" and one for "you need an in-person visit by a date." Have both approved before the holidays.
6. Watch the Federal Register daily from mid-November. The fourth extension appeared on December 31. Assign one person to check, and give them authority to trigger the plan.

Our DEA Telemedicine Readiness engagement ($1,450) builds the patient inventory, the in-person plan and the decision tree for each outcome, and our Compliance Calendar & Rule Watch ($495 per month) covers the daily watch. The background on all of this lives on our DEA telemedicine rules hub. Nothing here is legal advice; take the plan to your counsel.